eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Salivary Glands

Parotitis: Differential Diagnoses & Workup

Author: Jerry W Templer, MD, Professor of Otolaryngology, University of Missouri Medical Center at Columbia
Coauthor(s): Benjamin Daniel Liess, MD, Assistant Professor, Department of Otolaryngology, University of Missouri-Columbia School of Medicine
Contributor Information and Disclosures

Updated: Jul 6, 2009

Differential Diagnoses

Salivary Gland Neoplasms

Other Problems to Be Considered

  • Metastases to lymph nodes within the parotid gland
  • Inflammation of lymph nodes within the parotid gland

Workup

Laboratory Studies

  • Chemical analysis of saliva
    • Anti-SS-A, anti-SS-B, and rheumatoid factor may be present in autoimmune diseases. Saliva may be cultured, which is helpful, and it may be analyzed chemically, which is rarely helpful.
    • Most laboratories cannot perform useful tests on saliva. Dental researchers had hopes for several decades that analysis of saliva would be of diagnostic importance. Saliva has such wide variations in composition that analysis has produced little of diagnostic value.

Imaging Studies

  • CT scanning and MRI with gadolinium enhancement
    • These studies may be used to determine the size, shape, and some qualities of neoplasms or swelling within the gland.
    • Either method reliably differentiates between solid masses, cystic lesions, and diffuse involvement of the gland.
  • Sialography
    • Sialography is used to demonstrate the anatomy of the drainage system and is a very useful test. Injury to the ducts or acini is demonstrated with this study. Many radiologists no longer perform the test, which is unfortunate. Most dentists can perform sialography in the office. The otolaryngologist can cannulate the duct and inject the dye in the radiology suite.
    • A scout radiograph should be made to rule out radiopaque stones or calcification within the gland.
    • A special cannula or #90 polyethylene tubing is inserted into the duct, and iodinated oil such as Ultravist (iopromide) oily Dionosil is injected into the ductal system.
    • The normal ducts can accommodate 0.50-0.75 mL without discomfort. The authors inject until the patient reports discomfort and then posteroanterior and lateral radiographs are obtained.
    • The study is repeated 5 minutes later. Usually, all of the contrast media has been evacuated.
    • The normal ductal system looks like a deciduous tree in winter. In sialectasis, the radiographs may have the appearance of a tree with scattered leaves (see Image 3). The ductal system may be dilated and demonstrate numerous small strictures giving the appearance of "sausaging."

    • Sialogram of patient with sialectasis. Notice the...

      Sialogram of patient with sialectasis. Notice the appearance of a tree with leaves.

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      Sialogram of patient with sialectasis. Notice the...

      Sialogram of patient with sialectasis. Notice the appearance of a tree with leaves.

  • Ultrasonography is much easier to perform than sialography and seems to be replacing sialography in many institutions. It demonstrates solid masses or fluid collections within the gland. It also can detect hypoechoic areas that correspond to punctate sialectasis by sialography. It is not as sensitive as sialography, but this is probably not clinically significant.

Procedures

Interventional sialoendoscopy
This technique is growing in popularity and availability and seems to be the best method of treatment.12 The duct is anesthetized and dilated to insert a telescope for inspection of the large ducts. A working channel in the telescope permits irrigation, suction, and insertion of forceps, wire loop, or even laser energy via a glass fiber to remove the calculi. The clinician has much more information as to the condition of the duct system. This instrument is useful for the assessment and treatment of several inflammatory disorders of the gland. 

Incisional biopsy

  • Under local anesthesia, a biopsy of the tail of the gland may be obtained by an experienced surgeon without injury to the facial nerve.
    • Fine-needle aspiration biopsy frequently is diagnostic for tumors and may be helpful to identify cell types and to obtain material for cultures when the clinical picture suggests infection.
    • Excisional biopsy of a labial minor salivary gland may be diagnostic when the clinical picture suggests Sjögren syndrome.

Histologic Findings

Excision of parotid tissue is infrequently used for diagnosis. When removed for acute infection, acute necrosis of the glandular elements is observed. Autoimmune parotitis occasionally progresses to lymphoma, and biopsy is performed when suspected. Invasion by lymphocytes and destruction of the glandular elements are observed.

More on Parotitis

Overview: Parotitis
Differential Diagnoses & Workup: Parotitis
Treatment & Medication: Parotitis
Follow-up: Parotitis
Multimedia: Parotitis
References
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References

  1. Lilienthal HA. A method of incising parotid abscess without injury to the facial nerve distribution. Am J Surg. 1917;31(4):101-2.

  2. Hemenway WG, English GM. Surgical treatment of acute bacterial parotitis. Postgrad Med. Oct 1971;50(4):114-9. [Medline].

  3. Cope VZ. Acute necrotic parotitis. Br J Surg. 1919;7:130-3.

  4. Blair VP, Padgett EC. Pyogenic infection of the parotid glands and ducts. Arch Surg. 1923;7(1):1-36.

  5. Spiegel R, Miron D, Sakran W, Horovitz Y. Acute neonatal suppurative parotitis: case reports and review. Pediatr Infect Dis J. Jan 2004;23(1):76-8. [Medline].

  6. Baurmash HD. Chronic recurrent parotitis: a closer look at its origin, diagnosis, and management. J Oral Maxillofac Surg. Aug 2004;62(8):1010-8. [Medline].

  7. Beitler JJ, Vikram B, Silver CE, et al. Low-dose radiotherapy for multicystic benign lymphoepithelial lesions of the parotid gland in HIV-positive patients: long-term results. Head Neck. Jan-Feb 1995;17(1):31-5. [Medline].

  8. Henderson SO, Mallon WK. Tuberculosis as the cause of diffuse parotitis. Ann Emerg Med. Sep 1995;26(3):376-9. [Medline].

  9. Shaffer AJ, Jacobsen AW. Mikulicz's syndrome, a report of ten cases. Amer J Dis Child. 1927;34:342-6.

  10. Sjogren H. Keratoconjunctivitis sicca. Acta Ophthalmologica. 1933;Supplement 2:1-145.

  11. Hemenway WG. Chronic punctate parotitis. Laryngoscope. Apr 1971;81(4):485-509. [Medline].

  12. Papadaki ME, McCain JP, Kim K, Katz RL, Kaban LB, Troulis MJ. Interventional sialoendoscopy: early clinical results. J Oral Maxillofac Surg. May 2008;66(5):954-62. [Medline].

  13. Ericson S, Zetterlund B, Ohman J. Recurrent parotitis and sialectasis in childhood. Clinical, radiologic, immunologic, bacteriologic, and histologic study. Ann Otol Rhinol Laryngol. Jul 1991;100(7):527-35. [Medline].

  14. Ferraro FJ Jr, Rush BF Jr, Ruark D, Oleske J. Enucleation of parotid lymphoepithelial cyst in patients who are human immunodeficiency virus positive. Surg Gynecol Obstet. Nov 1993;177(5):524-6. [Medline].

  15. Fox RI, Kang HI. Pathogenesis of Sjögren's syndrome. Rheum Dis Clin North Am. Aug 1992;18(3):517-38. [Medline].

  16. Godwin JT. Benign lymphoepithelial lesion of the parotid gland adenolymphoma, chronic inflammation, lymphoepithelioma, lymphocytic tumor, Mikulicz disease. Cancer. Nov 1952;5(6):1089-103. [Medline].

  17. Mandel L, Witek EL. Chronic parotitis: diagnosis and treatment. J Am Dent Assoc. Dec 2001;132(12):1707-11; quiz 1727. [Medline].

  18. Morgan WS, Castleman B. A clinicopathologic study of Mikulicz's disease. Am J Pathol. May-Jun 1953;29(3):471-503. [Medline].

  19. Shaha AR, DiMaio T, Webber C, Thelmo W, Jaffe BM. Benign lymphoepithelial lesions of the parotid. Am J Surg. Oct 1993;166(4):403-6. [Medline].

  20. Wang S, Li J, Zhu X, et al. Gland atrophy following retrograde injection of methyl violet as a treatment in chronic obstructive parotitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Mar 1998;85(3):276-81. [Medline].

  21. Watkin GT, Hobsley M. Natural history of patients with recurrent parotitis and punctate sialectasis. Br J Surg. Sep 1986;73(9):745-8. [Medline].

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Further Reading

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Keywords

parotitis, sialadenitis, acute bacterial parotitis, chronic bacterial parotitis, chronic recurrent parotitis, infectious parotitis, acute parotitis in neonates, acute viral parotitis, mumps, HIV parotitis, HIV parotitis in children, acute surgical parotitis, lymphoepithelial lesion, chronic punctate parotitis, autoimmune parotitis, Mikulicz disease, Sjögren disease, lymphoepithelial lesion of Godwin, recurrent parotitis of childhood, EBV infection, Epstein-Barr virus infection, parotitis in tuberculosis, sarcoidosis

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Contributor Information and Disclosures

Author

Jerry W Templer, MD, Professor of Otolaryngology, University of Missouri Medical Center at Columbia
Jerry W Templer, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, Missouri State Medical Association, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Benjamin Daniel Liess, MD, Assistant Professor, Department of Otolaryngology, University of Missouri-Columbia School of Medicine
Benjamin Daniel Liess, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Laryngological Rhinological and Otological Society, American Medical Association, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ted L Tewfik, MD, FRCS(C), Professor, Department of Otolaryngology, Director of Continuing Medical Education of Otolaryngology, McGill University Medical School; Director, Director of Professional Affairs of Otolaryngology, Department of Otolaryngology, Montreal Children's Hospital; Senior Staff, Montreal General Hospital and Royal Victoria Hospital
Ted L Tewfik, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society of Pediatric Otolaryngology, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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